Fatigue at the end of life is multidimensional, and its underlying pathophysiology is poorly understood. Factors that may contribute to fatigue include physical changes, psychological dynamics, and adverse effects associated with the treatment of the disease or associated symptoms. Stimulant medications, along with energy conservation, may be warranted. (Refer to the PDQ summary on Fatigue for more information.)
In some patients, chronic coughing at the end of life may contribute to suffering. Chronic cough can cause pain, interfere with sleep, aggravate dyspnea, and worsen fatigue. At the end of life, aggressive therapies are not warranted and are more likely to cause increased burden or even harm. Symptom control rather than treatment of the underlying source of the cough is warranted at this time of life. Opioids are strong antitussive agents and are frequently used to suppress cough in this setting. Corticosteroids may shrink swelling associated with lymphangitis. Antibiotics may be used to treat infection and reduce secretions leading to cough. Patients with cancer may have comorbid nonmalignant conditions that can lead to cough. For example, bronchodilators are useful in the management of wheezing and cough associated with chronic obstructive pulmonary disease, and diuretics may be effective in relieving cough due to cardiac failure. Additionally, a review of medications is warranted because some drugs (e.g., ACE inhibitors) can cause cough.
Anecdotal evidence suggests a role for inhaled local anesthetics, which should be utilized judiciously and sparingly; they taste unpleasant and suppress the gag reflex, and anaphylactic reactions to preservatives in these solutions have been documented. In cases of increased sputum production, expectorants and mucolytics have been employed, but the effects have not been well evaluated. Inhaled sodium cromoglycate has shown promise as a safe method of controlling chronic coughing related to lung cancer.
Refer to the PDQ summary on Cardiopulmonary Syndromes for more information.
Rattle, also referred to as death rattle, occurs when saliva and other fluids accumulate in the oropharynx and upper airways in a patient who is too weak to clear the throat. Rattle does not appear to be painful for the patient, but the association of this symptom with impending death often creates fear and anxiety for those at the bedside. Rattle is an indicator of impending death, with an incidence of approximately 50% in people who are actively dying. There is some evidence that the incidence of rattle can be greatly reduced by avoiding the tendency to overhydrate patients at the end of life.[57,58]
In one prospective study of 100 terminally ill cancer patients, rattle began at an average of 57 hours before death.[Level of evidence: II] Other studies suggest the median time from onset of rattle to death is much shorter at 16 hours. Two types of rattle have been identified: real death rattle, or type 1, which is probably caused by salivary secretions; and pseudo death rattle, or type 2, which is probably caused by deeper bronchial secretions due to infection, tumor, fluid retention, or aspiration.[58,61] In one retrospective chart review, rattle was relieved in more than 90% of the patients with salivary secretions, while patients with secretions of pulmonary origin were much less likely to respond to treatment.